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Original Investigation | Journal Club

Concussion Symptoms and Return to Play Time in Youth, High School, and College American Football Athletes

Zachary Y. Kerr, PhD, MPH1; Scott L. Zuckerman, MD2; Erin B. Wasserman, PhD3; Tracey Covassin, PhD, AT, ATC4; Aristarque Djoko, MS1; Thomas P. Dompier, PhD, ATC1
[+] Author Affiliations
1Datalys Center for Sports Injury Research and Prevention Inc, Indianapolis, Indiana
2Department of Neurological Surgery, Vanderbilt Sports Concussion Center, Vanderbilt University School of Medicine, Nashville, Tennessee
3Matthew Gfeller Sport-Related Traumatic Brain Injury Research Center at University of North Carolina, Chapel Hill
4Department of Kinesiology, Michigan State University, East Lansing
JAMA Pediatr. 2016;170(7):647-653. doi:10.1001/jamapediatrics.2016.0073.
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Importance  To our knowledge, little research has examined concussion across the youth/adolescent spectrum and even less has examined concussion-related outcomes (ie, symptoms and return to play).

Objective  To examine and compare sport-related concussion outcomes (symptoms and return to play) in youth, high school, and collegiate football athletes.

Design, Setting, and Participants  Athletic trainers attended each practice and game during the 2012 to 2014 seasons and reported injuries. For this descriptive, epidemiological study, data were collected from youth, high school, and collegiate football teams, and the analysis of the data was conducted between July 2015 and September 2015. The Youth Football Surveillance System included more than 3000 youth football athletes aged 5 to 14 years from 118 teams, providing 310 team seasons (ie, 1 team providing 1 season of data). The National Athletic Treatment, Injury, and Outcomes Network Program included 96 secondary school football programs, providing 184 team seasons. The National Collegiate Athletic Association Injury Surveillance Program included 34 college football programs, providing 71 team seasons.

Main Outcomes and Measures  We calculated the mean number of symptoms, prevalence of each symptom, and the proportion of patients with concussions that had long return-to-play time (ie, required participation restriction of at least 30 days). Generalized linear models were used to assess differences among competition levels in the mean number of reported symptoms. Logistic regression models estimated the odds of return to play at less than 24 hours and at least 30 days.

Results  Overall, 1429 sports-related concussions were reported among youth, high school, and college-level football athletes with a mean (SD) of 5.48 (3.06) symptoms. Across all levels, 15.3% resulted return to play at least 30 days after the concussion and 3.1% resulted in return to play less than 24 hours after the concussion. Compared with youth, a higher number of concussion symptoms were reported in high school athletes (β = 1.39; 95% CI, 0.55-2.24). Compared with college athletes, the odds of return to play at least 30 days after injury were larger in youth athletes (odds ratio, 2.75; 95% CI, 1.10- 6.85) and high school athletes (odds ratio, 2.89; 95% CI, 1.61-5.19). The odds of return to play less than 24 hours after injury were larger in youth athletes than high school athletes (odds ratio, 6.23; 95% CI, 1.02-37.98).

Conclusions and Relevance  Differences in concussion-related outcomes existed by level of competition and may be attributable to genetic, biologic, and/or developmental differences or level-specific variations in concussion-related policies and protocols, athlete training management, and athlete disclosure. Given the many organizational, social environmental, and policy-related differences at each level of competition that were not measured in this study, further study is warranted to validate our findings.

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Public policy gaps lead to mismanagement of younger athletes
Posted on May 6, 2016
Daniel Kantor MD FAAN
Kantor Neurology
Conflict of Interest: Daniel Kantor, MD, FAAN is the Chair of the Subcommittee on Concussion of the Sports Medicine Advisory Committee for the Florida High School Athletics Association (FHSAA) and the Past President of the Florida Society of Neurology (FSN).
We appreciate the analysis performed by Kerr et al. that highlights gaps in management for our youngest athletes. Alarmingly, despite the youngest athletes having the highest rate of concussions, 10% of them inappropriately returned to play less than 24 hours from the time of the injury. All 50 states now have some form of a concussion law intended to protect youth athletes, generally focused at the high school level. The lack of uniformity in protecting younger athletes , including those in youth leagues, may explain the lack of adherence to the international (\"Zurich\") consensus guidelines for return-to-play.

In Florida, we have recognized this public policy gap and are taking action to strengthen concussion policies in our state by collaborating with the Department of Education to ensure a uniform concussion policy for students throughout the spectrum of their academic careers (K - 12 and beyond) regardless o the location/circumstance of the concussion (on or off the sports field) and we are moving beyond return-to-play to establishing statewide return-to-learning guidelines.

The issues raised in the article by Kerr et al., highlight the need for secured electronic databases to capture all concussions.
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